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Title: Operative and diagnostic strategies in pelvic floor disease and incontinence
Author: Tan, Emile John Kwong-Wei
ISNI:       0000 0004 2724 6019
Awarding Body: Imperial College London
Current Institution: Imperial College London
Date of Award: 2012
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Introduction: Pelvic floor disease affects many patients, with age, female gender and multiparity being significant associations. This can present clinically as pelvic organ prolapse, internal and external rectal mucosal intussuception, obstructed defecation syndrome, rectocele, cystocele and urinary/faecal incontinence. Diagnostic and treatment strategies for the management of such disorders is significantly varied, and evidence for current surgical management is poor. This thesis explores diagnostic and operative strategies currently regarded as state of the art and examines a novel method of pelvic floor assessment using MRI-based statistical shaped modelling. Methods: Meta-analysis in accordance with Cochrane collaboration guidelines was performed to assess laparoscopic versus open techniques for urinary incontinence, as well as endoanal ultrasound (EUS) scanning versus MRI in the assessment of faecal incontinence. The efficacy of sacral nerve stimulation (SNS) was reviewed. In addition, decision analysis was performed to assess the cost-effectiveness of delayed versus immediate anal sphincter repairs, and current operative treatments for end-stage faecal incontinence, and operative strategies for end-stage incontinence. MRI-based statistical shaped biomechanical modelling was performed to assess normal pelvic floors in comparison with patients with obstructed defecation syndrome. 15 asymptomatic volunteers aged 18 to 60 years were scanned and compared against 7 with obstructed defecation (ODS). Finally, 7 patients who were treated surgically for ODS were reassessed 6 months post-operation. Results: There were significant benefits to laparoscopic colposuspension for urinary incontinence. EUS was superior to MRI at detecting internal sphincter lesions, but not for external sphincter lesions. Immediate sphincter repairs were more cost-effective than delayed repairs. The artificial bowel sphincter and end stoma were more acceptable to both patient and institution than dynamic graciloplasty. Patients with obstructed defecation had significantly more irregular levator muscles with wider levator hiatus. Pressure during straining was concentrated in the posterior aspect of the hiatus, potentially contributing to the rectal neuropathy noted in obstructed defecation. Conclusions: Sacral nerve stimulation is an effective treatment for faecal incontinence. The artificial bowel sphincter and end stoma were cost-effective long-term strategies for end-stage faecal incontinence. A new technique for dynamic imaging and functionally assessing pelvic floor musculature has been developed and is showing promise as an adjunct to conventional assessment. Conventional defecating proctography does not provide the dynamic and functional assessment provided by this technique, and may translate well into a means of functional radiological assessment in the future.
Supervisor: Tekkis, Paris ; Khullar, Vik Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral